Are you a candidate for laser hair removal?
Have you been considering laser hair removal, but unsure whether or not you are a candidate. Complete the following questionnaire to find out!

1. What have you previously used to remove unwanted hair? Please select all that apply.

Nothing Waxing Tweezing Shaving Nair/Epilstop Bleaching

2. What areas are you interested in getting laser hair removal?

Underarms

Face

Bikini

Arms

Legs

Back

Chest

3. What color is your hair in the area you want to be treated?

Black

Brown

Blonde

Grey

White

Light Brown

Light Blonde

Red

4. What color is your skin in the area you want to be treated? (be specific)

White

Brown

Black

Light Brown

5. Are you sun tanned?

Tan

Slight Tan

No Tan

6. What is your type in the area you are considering to have laser hair removal?

	Type 1 – Always burn, never tan (extremely fair skin/blond hair/blue/green eyes)
	Type 2 - Usually burn, tan less than about average (fair skin, sandy brown to brown hair, green/blue eyes)
	Type 3 – Sometimes mild burn, tan about average (medium skin, brown hair, green/brown eyes)
	Type 4 – Rarely burn, tan more than average (medium skin, brown hair, green/brown eyes)
	Type 5 – Moderately pigmented, tans profusely (dark brown skin, black hair, black eyes)
	Type 6 – Deeply pigmented, never burns (black skin, black hair, black eyes)

7. Have you been on Accutane in the past 6 months?

Yes

No

8. Are you currently on any medication?

Yes

No

If yes, does it cause photosensitivity?
	Yes		No		Not Sure

What is the name of the medication?

Any other questions you would like answered:

9. Personal Information: All Information is Strictly Confidential!

*Name

*Address

*City

*State

- Select - Non US Alabama Alaska Arizona Arkansas California Colorado Connecticut District of Columbia Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming D.C. Puerto Rico Virgin Islands Guam

*Province / Region (Outside U.S. Only)

*Zip Code/ Postal Code

*Country

- Select - USA Canada Bahama Islands United Kingdom Other

*Phone Number

Would you like us to call you? (strictly confidential)

Yes

No

*10. What e-mail address would you like the analysis results sent to? E-mail must be provided to receive information!